Test bank

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the clients gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

c. Document findings and continue to monitor.

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurses aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

c. Give the client a bedpan or urinal to use.

The adult male patient with significant body hair is being prepared for abdominal surgery. The patient states his dad had the same surgery many years ago and was shaved prior to the procedure. The nurse would explain to the patient: A) That practice is no longer standard as shaving may cause breaks in the skin. B) We no longer shave skin before procedures but we will apply a lotion that will remove the hair. C) Your abdomen will be shaved in the operating room. D) You will be shaved as well.

A) That practice is no longer standard as shaving may cause breaks in the skin.

The nurse knows the term perioperative phase refers to care given to the client A) Before, during, and after the operative phase B) From the start of surgery until its conclusion C) Immediately before an operative procedure D) Immediately after the operative phase

A) Before, during, and after the operative phase

Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? A) I can have a hamburger and French fries as soon as I wake up. B) The better I eat before surgery, the more likely I will heal. C) I might be sick to my stomach and throw up after surgery. D) When I can eat again, the best meal would be steak and orange juice.

A) I can have a hamburger and French fries as soon as I wake up.

Which of the following nursing actions provides the greatest assistance in healing? A) Maintaining a restful environment B) Providing solid food in the first day C) Allowing family members to visit often D) Keeping the client recumbent

A) Maintaining a restful environment

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in A) Protein B) Calcium C) Bicarbonate D) Potassium

A) Protein

Which of the following personnel are legally responsible for obtaining the patients informed consent for a surgical procedure? A) The surgeon B) The registered nurse C) The admissions clerk D) The licensed practical nurse E) Any licensed person

A) The surgeon

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.

ANS: A, B, C, D a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment.

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present e. Removing hearing aids

ANS: A, B, C, D a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

ANS: A, B, C, D a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

ANS: A, B, C, E a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL e. Young male client with a RYR1 gene mutation

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

ANS: A, B, C, E a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep.

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldnt drive while you are taking this medication.

ANS: A, B, C, E a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. e. You shouldnt drive while you are taking this medication.

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

ANS: A, B, D, E a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the clients shoulder and arm on the operating table d. Preparing to suction the clients airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C a. Assessing distal circulation to the operative arm after positioning c. Padding the clients shoulder and arm on the operating table

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. A malnourished client will have fragile skin. b. Malnourished clients always have other problems. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

ANS: A, C, D, E a. A malnourished client will have fragile skin. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

ANS: A, C, D, E a. Metformin (Glucophage) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

ANS: A, D, E a. Dressing the surgical wound d. Suctioning the surgical site e. Suturing the surgical wound

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the clients safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

ANS: A, E a. Ensuring the clients safety e. Monitoring traffic in the room

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

ANS: B, C, D b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

ANS: B, C, D, E b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

ANS: B, C, D, E b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

ANS: B, C, E b. Infection c. Serious cardiac events e. Thromboembolism

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

ANS: B, D, E b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

ANS: B, E b. Liver biopsy: diagnostic e. Total shoulder replacement: restorative

The nursing instructor is discussing the role of the circulating nurse in the operative suite with the student nurses. Which of the following would the nursing instructor include as duties of the circulating nurse? Select all that apply. A) The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. B) The circulating nurse is responsible for preparing the surgical table for the procedure. C) The circulating nurse is responsible for assisting the surgeon with instruments during the procedure. D) The surgical nurse is responsible for maintaining the patients rights during the surgical procedure.

Ans: A, D A) The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. D) The surgical nurse is responsible for maintaining the patients rights during the surgical procedure.

The nurse is caring for a patient admitted for an outpatient surgical procedure. Which of the following will the nurse include in the care? A) Begin discharge teaching as soon as the procedure is completed. B) Allow family members to be present during discharge teaching. C) Begin discharge teaching in the preoperative period. D) Investigate the patients home care and discharge transportation following the procedure. E) Discuss discharge transportation during the preoperative period.

Ans: B, C, E B) Allow family members to be present during discharge teaching. C) Begin discharge teaching in the preoperative period. E) Discuss discharge transportation during the preoperative period.

Which of the following surgical clients will return to activities in their everyday lives more quickly? A) Vaginal hysterectomy B) Laparoscopic cholecystectomy C) Right nephrectomy D) Open-heart surgery

B) Laparoscopic cholecystectomy

The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects A) Myocardial infarction B) Malignant hyperthermia C) Mitral valve prolapse D) Major blood loss

B) Malignant hyperthermia

What nursing action will assist in pain management for a client in the postoperative phase? A) Client teaching B) Relaxation techniques C) Dim lighting D) Provide food and medication

B) Relaxation techniques

A client has arrived in the same-day surgery suite. He states to the nurse, I am so worried about being put to sleep and having the surgery. What would be the nurses best response? A) You don't have to worry. It will be fine. B) Tell me what you are most worried about. C) I will have the anesthesiologist talk to you. D) Have you ever had surgery before?

B) Tell me what you are most worried about.

The nurse is preparing to start an IV in the preoperative adult patient. The nurse would likely choose which gauge of IV catheter? A) 22 gauge B) 25 gauge C) 18 gauge D) 14 gauge

C) 18 gauge

A client has been taking aspirin since his heart attack in 1997. The client is at risk for A) Infection B) Thrombophlebitis C) Hemorrhage D) Blood clots

C) Hemorrhage

Which of the following clients will see the greatest permanent changes in lifestyle following surgery? A) Right total knee replacement B) Left mastectomy C) Ileostomy D) Appendectomy

C) Ileostomy

When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of A) Effects of anesthesia B) Normal return of reflexes C) Partial airway obstruction D) Type of surgery

C) Partial airway obstruction

A client in the immediate postoperative period begins to complain of nausea and ultimately begins vomiting. The nausea and vomiting is most likely related to A) Movement of bowels during surgery B) Inactivity and emotional upset C) The effects of anesthetic agents D) Severe pain at the operative site

C) The effects of anesthetic agents

The nurse is caring for the postoperative patient in the PACU. The patient is concerned about the abdominal staples closing her wound for fear they will open and her insides will fall out. Which of the following is the best response by the nurse? A) Don't worry, the staples are properly placed and will not come out until they are removed by the physician. B) If you are very careful and follow your postoperative instructions, there is no need to worry. C) There are sutures in various levels below the staples that assist in keeping your wound intact. D) Would you tell me why you are worried about that? E) That is possible, but we will keep a close eye on the staples.

C) There are sutures in various levels below the staples that assist in keeping your wound intact.

What is the rationale for having the client void before surgery? A) To assess for pregnancy in women B) To assess for urinary tract infection C) To prevent bladder distention D) To prevent electrolyte imbalance

C) To prevent bladder distention

The recovery nurse is caring for a surgical patient in the PACU. The patients blood pressure is dropping and their heart rate is increasing. The nurse suspects the patient is: A) overmedicated. B) experiencing normal adaptation to the postoperative period. C) allergic to the anesthesia. D) developing shock.

D) developing shock.

The removal of a toddlers clothing and application of monitoring equipment after anesthesia is administered will A) Minimize blood loss B) Ensure temperature control C) Provide baseline vital signs D) Allow sufficient relaxation

D) Allow sufficient relaxation

Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia? A) A woman delivering by C-section B) An adolescent for arthroscopic surgery C) A young adult with a fractured leg D) An elderly man with a fractured hip

D) An elderly man with a fractured hip

The preoperative patient has called the nurse about his upcoming surgical procedure, which will be six weeks from now. He is concerned about receiving blood after surgery for fear of acquiring a bloodborne disease. Which of the following might the nurse do? A) Instruct the patient to notify the physician. B) Remind the patient that blood is tested prior to administration, making it safe and free of disease. C) Ask the patient if he has ever had any blood products. D) Explain to the patient the use of autologous blood donation. E) Instruct patient to refuse transfusion.

D) Explain to the patient the use of autologous blood donation.

The healthy adult patient is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the patient. Which of the following should the nurse do first? A) Immediately have the patient sign the consent form. B) Have the patients family member sign the consent form. C) Ask the patient if he still wants to proceed with the procedure. D) Notify the physician of the oversight.

D) Notify the physician of the oversight.

In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain, and in the second postoperative day, the clients bowel sounds are absent. What does the nurse suspect? A) Normal response B) Abdominal infection C) Hernia development D) Paralytic ileus

D) Paralytic ileus

A client states he has a latex allergy. What action should the nurse take? A) Inform the client to tell the anesthesiologist B) Have the client take a Benadryl before surgery C) Send the client to the OR with epinephrine D) Place an allergy identification band

D) Place an allergy identification band

Following a surgical procedure, which of the following are generally responsible for moving the patient to the recovery area? A) The surgeon B) The orderly C) The recovery nurses D) The anesthesiologist, circulating nurse, and surgeon

D) The anesthesiologist, circulating nurse, and surgeon

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. A rapid heart rate requires more effort by the heart. b. Anesthesia has bad effects if the client is tachycardic. c. The client may have an undiagnosed heart condition. d. When the heart rate goes up, the blood pressure does too.

a. A rapid heart rate requires more effort by the heart.

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

a. Administer 10 units of regular insulin For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly.

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

a. Airway

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

a. Allow the client to keep hearing aids in until anesthesia begins.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

a. Ask the client to describe current feelings.

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

a. Assess other indicators of oxygenation.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

a. Assess the client for anxiety.

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the clients end-tidal carbon dioxide level. b. Document the findings in the clients chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

a. Assess the clients end-tidal carbon dioxide level.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

a. Change in behavior

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the clients chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

a. Consult the surgeon about a postoperative dietitian referral.

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

a. Explain the rationale for giving the medicine now.

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

a. Facilitate marking the site with the client and surgeon.

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

a. Flumazenil (Romazicon) 0.2 to 1 mg

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

b. Assist the client into a position of comfort.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

b. Auscultate lung sounds.

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. After you wash the surgical site, shave that area with your own razor. b. Be sure to wash the area where you will have surgery very thoroughly. c. Use a washcloth to wash the surgical site; do not take a full shower or bath. d. Wash the surgical site first, then shampoo and wash the rest of your body.

b. Be sure to wash the area where you will have surgery very thoroughly.

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

b. Being prepared to suction the airway

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

b. Consent for MIS procedure only

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

b. Demonstrate how to splint the incision.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

b. Do not have the client sign the consent and call the surgeon.

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the clients anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

b. Give the client a back rub.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. All preoperative clients get this medication. b. It helps prevent ulcers from the stress of the surgery. c. Since you dont have ulcers, I will have to ask. d. The physician prescribed this medication for you.

b. It helps prevent ulcers from the stress of the surgery.

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

b. Perform hand hygiene and apply gloves.

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

b. Place the client on a cardiac monitor and pulse oximeter.

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the clients vital signs. d. Teach relaxation techniques.

b. Raise the siderails on the bed.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

b. There is no redness, warmth, or drainage at the insertion site.

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

c. Inform the surgeon that the sterile field has been broken.

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

c. Lower the head of the bed.

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

c. Metoclopramide (Reglan)

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

c. Older adult who lives at home despite some memory loss

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

c. Potassium: 2.9 mEq/L A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status.

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

d. Participating in hand-off report

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

d. Psychosocial status

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

d. Remain with the client.

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.

d. Sometimes older people take longer to wake up.

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.

d. To prevent blood clots you need them a few more hours.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d. Use of multiple herbs and supplements

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.

d. Wash your hands before touching the drain or dressing.

A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the clients A) Family relationships B) Return to daily activities C) Decision making D) Self-concept

D) Self-concept

The patient has been transported to the operating suite and positioned on the operating table. Suddenly, the patient states, I dont want to do this. Get me out of here now! Which of the following actions should occur? A) The patient should be given the anesthesia. B) The surgeon should tell the patient to remain calm and the procedure will be over soon. C) The patient should be told it is too late to change his mind. D) The procedure should be stopped.

D) The procedure should be stopped.

What is the rationale for the administration of IV cephalosporin antibiotic before surgery? A) To prevent the development of strep B) To prevent the development of pneumonia C) To allow for decreased level of white blood cells D) To allow the client high levels of medication

D) To allow the client high levels of medication A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the clients blood will be high during surgery.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

c. Get another piece of equipment.

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best? a. Call a time-out to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeons actions to the charge nurse and unit manager.

b. Document the time the robotic portion of the procedure begins.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)

c. Client with a respiratory rate of 6 breaths/min

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain

c. Securing the drains safety pin to the sheets